Medplum

<?xml version="1.0" encoding="UTF-8"?> <?xml-stylesheet type="text/xsl" href="CDA.xsl"?> <ClinicalDocument xmlns = "urn:hl7-org:v3" xmlns:xsi = "http://www.w3.org/2001/XMLSchema-instance" xmlns:voc = "urn:hl7-org:v3/voc" xmlns:sdtc = "urn:hl7-org:sdtc"> <realmCode code = "US"/> <typeId extension = "POCD_HD000040" root = "2.16.840.1.113883.1.3"/> <templateId root = "2.16.840.1.113883.10.20.22.1.1" extension = "2015-08-01"/> <templateId root = "2.16.840.1.113883.10.20.22.1.1"/> <templateId root = "2.16.840.1.113883.10.20.22.1.2" extension = "2015-08-01"/> <templateId root="2.16.840.1.113883.10.20.22.1.2" /> <id root="3db70aff-83f5-4caf-91dc-d23fcc5e03bb" /> <code code="34133-9" displayName="Summarization of Episode Note" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" /> <title>Medical Summary</title> <effectiveTime value="20250101000000-0500" /> <languageCode code="en-US" /> <recordTarget> <patientRole> <id root="d7830f15-e2c8-4cee-aa2d-a24b36080d53" /> <id extension="111223333" root="2.16.840.1.113883.4.1" /> <telecom nullFlavor="UNK" /> <addr nullFlavor="UNK" /> <patient> <name use="L"> <given>Katherine</given> <family>Madison</family> </name> <raceCode nullFlavor="UNK"/> <ethnicGroupCode nullFlavor="UNK"/> </patient> </patientRole> </recordTarget> <component> <structuredBody> <component> <section> <templateId root="2.16.840.1.113883.10.20.22.2.4.1" extension="2015-08-01" /> <code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Vital signs" /> <title>Vital Signs</title> <text> <table> <thead> <tr> <th>Vital Sign</th> <th>Reading</th> <th>Time Taken</th> </tr> </thead> <tbody> <!-- These 2 rows are for vitals taken when the patient was around 1 year old. At this time, when the patient is a 1 year old male, they fall into the recommendation of using the WHO 0-2 years charts. Note that there are no recommended charts for BMI when the patient is younger than 2 years old, so that value is not included here. --> <tr ID="WfLPerc_1"> <td> <content ID="WfLPerc_1Name">Weight-for-length Percentile</content> (<content ID="WfLPerc_1GC">WHO Males, 0-2 years Chart</content> ) </td> <td>50 %</td> <td>05/20/2014 7:36 PM</td> </tr> <tr ID="headCircPerc_1"> <td> <content ID="headCircPerc_1Name">Head Circumference Percentile</content> (<content ID="headCircPerc_1GC">WHO Males, 0-2 years Chart</content>) </td> <td>45 %</td> <td>05/20/2014 7:36 PM</td> </tr> <!-- These 3 rows are for vitals taken when the patient was around 2.5 years old At this time, when the patient is a 2.5 year old male, they fall into the recommendation of using the CDC 2-20 years charts. However, Head circumference percentile is not in the the CDC 2-20 years charts. For Head circumference percentile, the CDC 0-36 months chart should be used for patients 24-36 months old (note that when the patient is 0-2 years old WHO 0-2 years chart should be used). --> <tr ID="bmiPerc_2"> <td> <content ID="bmiPerc_2Name">Body Mass Index Percentile</content> (<content ID="bmiPerc_2GC">CDC Males, 2-20 years Chart</content>) </td> <td>49 %</td> <td>11/20/2015 7:36 PM</td> </tr> <tr ID="WfLPerc_2"> <td> <content ID="WfLPerc_2Name">Weight-for-length Percentile</content> (<content ID="WfLPerc_2GC">CDC Males, 2-20 years Chart</content>) </td> <td>48 %</td> <td>11/20/2015 7:36 PM</td> </tr> <tr ID="headCircPerc_2"> <td> <content ID="headCircPerc_2Name">Head Circumference Percentile</content> (<content ID="headCircPerc_2GC">CDC Males, 0-36 months Chart</content>) </td> <td>50 %</td> <td>11/20/2015 7:36 PM</td> </tr> </tbody> </table> </text> <entry> <!-- The organizer is the Vital Sign Organizer defined in the C-CDA Implementation Guide and represents the vitals taken at the same time - when the patient was around 1 year old. These observations all use the WHO Males, 0-2 years growth chart. This example omits Provenance for brevity. --> <organizer classCode="CLUSTER" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.26" /> <templateId root="2.16.840.1.113883.10.20.22.4.26" extension="2015-08-01" /> <id root="1a70f2d9-d576-466e-ba5c-003da6fb2107" /> <id extension="5610719400-Z197199" root="1.2.840.114350.1.13.861.1.7.1.2109" /> <code code="46680005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Vital signs"> </code> <statusCode code="completed" /> <effectiveTime value="20140520193605-0600" /> <!-- The components are all based on the Vital Sign Observation template defined in the C-CDA Implementation Guide, just with different LOINC Codes --> <!-- Weight-for-length Percentile --> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27" /> <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" /> <id root="701c0a9a-d25c-4d74-9149-5659eb446557" /> <id extension="5610719400-WfLPerc-Z197199" root="1.2.840.114350.1.13.861.1.7.1.2109.1" /> <code code="77606-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Weight-for-length Per age and sex"> </code> <!-- This reference identifies content in human readable formatted text--> <text> <reference value="#WfLPerc_1" /> </text> <statusCode code="completed" /> <effectiveTime value="20140520193605-0600" /> <value xsi:type="PQ" unit="%" value="50" /> <referenceRange> <observationRange> <!-- Since Weight-for-length Percentile is dependent on which Growth Chart is used to determine percentile, that is important to include. This indicates that the patient was in the 50th percentile of weight-for-lengths using the Males, 0-2 years WHO Weight-for-length Growth Chart. --> <!-- If future LOINC codes are assigned for specific growth charts it may affect value/@code and other places --> <text> <reference value="#WfLPerc_1GC" /> </text> <value xsi:type="ED"> <reference value="#WfLPerc_1GC" /> </value> </observationRange> </referenceRange> </observation> </component> <!-- Head Circumference Percentile --> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27" /> <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" /> <id root="fb9c8da2-c2f3-46cc-85d1-c1098032f1f5" /> <id extension="5610719400-headCirPerc-Z197199" root="1.2.840.114350.1.13.861.1.7.1.2109.1" /> <code code="8289-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Head Occipital-frontal circumference Percentile"> </code> <!-- This reference identifies content in human readable formatted text--> <text> <reference value="#headCircPerc_1" /> </text> <statusCode code="completed" /> <effectiveTime value="20140520193605-0600" /> <value xsi:type="PQ" unit="%" value="45" /> <referenceRange> <observationRange> <!-- Since Head Circumference Percentile is dependent on which Growth Chart is used to determine percentile, that is important to include. This indicates that the patient was in the 45th percentile of head circumferences using the Males, 0-2 years WHO Head Circumference Growth Chart. --> <text> <reference value="#headCircPerc_1GC" /> </text> <value xsi:type="ED"> <reference value="#headCircPerc_1GC" /> </value> </observationRange> </referenceRange> </observation> </component> </organizer> </entry> <entry> <!-- This is the second vital signs organizer, used to show the vitals from around a year and a half later after the previous organizer. This is when the patient is about 2.5 years of age. At this point, the recommendation from CDC would be to use the following growth charts - Weight for Length - CDC 2-20 year old charts - BMI Percentile - CDC 2-20 year old charts - Head Circumference - CDC Males, 0-36 months Chart --> <organizer classCode="CLUSTER" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.26" /> <templateId root="2.16.840.1.113883.10.20.22.4.26" extension="2015-08-01" /> <id root="1791f1e7-9642-4b51-be66-997de22370bb" /> <id extension="5710719405-Z197199" root="1.2.840.114350.1.13.861.1.7.1.2109" /> <code code="46680005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Vital signs"></code> <statusCode code="completed" /> <effectiveTime value="20151120193605-0600" /> <!-- The components are all based on the Vital Sign Observation template defined in the C-CDA Implementation Guide, just with different LOINC Codes --> <!-- BMI Percentile --> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27" /> <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" /> <id root="15c8bd35-b9dc-4da7-a13d-70b9618bc945" /> <id extension="5710719405-BMIPerc-Z197199" root="1.2.840.114350.1.13.861.1.7.1.2109.1" /> <code code="59576-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Body mass index (BMI) [Percentile] Per age and sex"> </code> <!-- This reference identifies content in human readable formatted text--> <text> <reference value="#bmiPerc_2" /> </text> <statusCode code="completed" /> <effectiveTime value="20151120193605-0600" /> <value xsi:type="PQ" unit="%" value="49" /> <referenceRange> <observationRange> <!-- Since BMI Percentile is dependent on which Growth Chart is used to determine percentile, that is important to include. This indicates that the patient was in the 49th percentile of BMIs using the Males, 2-20 Years CDC BMI Percentile Growth Chart. --> <text> <reference value="#bmiPerc_2GC" /> </text> <value xsi:type="ED"> <reference value="#bmiPerc_2GC" /> </value> </observationRange> </referenceRange> </observation> </component> <!-- Weight-for-length Percentile --> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27" /> <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" /> <id root="70ad5e83-58b8-453f-866a-afabd9e525fd" /> <id extension="5710719405-WfLPerc-Z197199" root="1.2.840.114350.1.13.861.1.7.1.2109.1" /> <code code="77606-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Weight-for-length Per age and sex"> </code> <!-- This reference identifies content in human readable formatted text--> <text> <reference value="#WfLPerc_2" /> </text> <statusCode code="completed" /> <effectiveTime value="20151120193605-0600" /> <value xsi:type="PQ" unit="%" value="48" /> <referenceRange> <observationRange> <!-- Since Weight-for-length Percentile is dependent on which Growth Chart is used to determine percentile, that is important to include. This indicates that the patient was in the 48th percentile of weight-for-lengths using the Males, 2-20 Years CDC Weight-for-length Growth Chart. --> <text> <reference value="#WfLPerc_2GC" /> </text> <value xsi:type="ED"> <reference value="#WfLPerc_2GC" /> </value> </observationRange> </referenceRange> </observation> </component> <!-- Head Circumference Percentile --> <component> <observation classCode="OBS" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.22.4.27" /> <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" /> <id root="cf5ac9f4-e31d-4066-8458-6f42be3877ef" /> <id extension="5710719405-headCirPerc-Z197199" root="1.2.840.114350.1.13.861.1.7.1.2109.1" /> <code code="8289-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Head Occipital-frontal circumference Percentile"> </code> <!-- This reference identifies content in human readable formatted text--> <text> <reference value="#headCircPerc_2" /> </text> <statusCode code="completed" /> <effectiveTime value="20151120193605-0600" /> <value xsi:type="PQ" unit="%" value="50" /> <referenceRange> <observationRange> <!-- Since Head Circumference Percentile is dependent on which Growth Chart is used to determine percentile, that is important to include. This indicates that the patient was in the 50th percentile of head circumferences using the CDC Males, 0-36 months Chart Head Circumference Growth Chart. --> <text> <reference value="#headCircPerc_2GC" /> </text> <value xsi:type="ED"> <reference value="#headCircPerc_2GC" /> </value> </observationRange> </referenceRange> </observation> </component> </organizer> </entry> </section> </component> </structuredBody> </component> </ClinicalDocument>